On a remote Forward Operating Base in Afghanistan’s westernmost province, U.S. Navy Lt. j.g. Laura Cook and U.S. Army Spc. Nkelo Kurtz have an uncommon partnership.
She is a Navy physician assistant on an individual augmentee assignment and he is an Army combat medic deployed with Bravo Battery 2-12 Field Artillery Regiment. Her home base is Naval Submarine Base Kings Bay, Ga., on the East Coast and he is based out of Joint Base Lewis-McChord in Tacoma, Washington, on the West Coast. Currently, they are both assigned to the Provincial Reconstruction Team Farah Medical Team.
As the only medical officer assigned to PRT Farah, Lt. j.g. Cook oversees daily operations of the base aid station and a staff of about ten medical personnel. She and her team provide care for all military, civilians and local national personnel working on the base.
Lt. j.g. Cook also works with provincial public health officials in a train, advise and assist role as part of the PRT’s primary mission. Spc. Kurtz assists her with aid station operations, including sick call services, supply and inventory and teaching combat life saver courses. He also supports PRT missions outside the wire as a duty medic.
When trauma patients are medically evacuated to the base, Cook and Kurtz’s team receives and triages them, and sends the most critical patients directly to the forward surgical team who are co-located on the base with the PRT’s medical team. Less critical patients are stabilized, evaluated and treated on-site.
In the following paragraphs Cook and Kurtz provide a glimpse into a typical day in their lives, each providing insight from their own experiences with Provincial Reconstruction Team Farah.
Mission Prep, Sick Call and Training
Spc. Kurtz: We prepare for sick call by inspecting our equipment to ensure it is in good working order, and our patient rooms to ensure they are stocked. It doesn’t seem like much, but it’s important to save time when patients come. We don’t want to have to search for an item in a supply container elsewhere on base, or spend time restocking when we could have had it pre-staged beforehand. The daily medic on duty also does maintenance checks on the field litter ambulance (a Humvee outfitted for patient transport) and the gator multi-use vehicle. We need these vehicles ready at a moment’s notice to pick up patients or drop off patients.
Lt. j.g. Cook: The clinic staff arrives and prepares for the day’s routine while the mission and quick-reaction force (QRF) medics are already busy with their respective duties. The mission medic will go out with other PRT personnel on missions if one is scheduled for the day. The QRF medic waits on base in a mission ready status in the event a supplementary force is needed by the team on mission.
Spc. Kurtz: Mission days are completely different than days working as the sick call medic on base. On mission days, pre-combat inspections and pre-combat gear checks are performed by the non-commissioned officers on the security force team to make sure that we all have the gear that we will need. Outside the wire, anything can happen – we have to be ready no matter what.
Lt. j.g. Cook: We hold sick call three times daily, except one day per week when we have sick call only once to recharge the medical staff’s batteries and handle any tasks not finished throughout the rest of the week. The variety of illnesses and injuries we see is astonishing for what most people consider a young and healthy, well-screened population. We most commonly see issues like diarrhea, bone fractures, Athlete’s foot and headaches, but we occasionally have to respond to an unforeseen diabetic emergency, a non-traumatic intra-cranial hemorrhage, viral hepatitis, or acute urinary obstruction, among other things. I never know what case Spc. Kurtz is going to give me when he walks into my office after meeting the patient and gathering baseline information – which he has become quite good at! Many times he has an idea of the likely diagnosis even before he comes to find me. After his assessment, we discuss the case together and then I finish my examination of the patient. Afterward, Spc. Kurtz performs any needed tests and then quickly fills prescriptions in our small pharmacy. While resources are limited here on the FOB, the aid station does have the ability to perform x-rays, electrocardiograms, and basic lab work.
Spc. Kurtz: Sick call is not the most fun job in the world sometimes, but it has to get done. We certainly see some interesting cases and I have definitely seen more here than back at home at Ft. Lewis. In the clinic I have seen cases of appendicitis, diabetes and even an accidental, self-inflicted stab wound . There are some patients who take precedence over others in order to save life, limb or eyesight, but the most common things I see are back pain, foot pain and cold symptoms. I usually have a pretty good idea of what someone’s illness is after talking to them, especially having been here for awhile.
Lt. j.g. Cook: Our PRT’s overall mission is to train, advise and assist Afghan leaders here in Farah, and the medical department plays a key role in that effort aside from taking care of medical needs on the FOB and providing medics for missions. While our civil affairs team and other PRT staff members might have a mission on a given day, I could also have a mission as well. I have attended meetings at the local provincial hospital with the Director of Public Health, which like our other meetings with our Afghan counterparts, are critical to our mission at the PRT. I have also attended provincial immunization council meetings and receive updates on communicable diseases in Farah through the province’s public health team. Last year there were 33 recorded cases of polio in the entire country, only one of them coming from Farah. With the help of the PRT, UNICEF, WHO, USAID and other organizations, the Farahis are making great strides to eradicate polio in the province and I’m confident they’ll be able to eradicate the disease here if they continue their efforts. The PRT also funds a supplemental feeding program for children age five and under who are malnourished. Our medical team checks in each month to ensure that the program is on track, that children are receiving the proper supplements, and that preventive education classes are being offered to mothers at each visit. Basic hygiene and topics such as breast care and child development are taught.
Lt. j.g. Cook: Several days per week we hold training sessions with the Forward Surgical Team. Topics usually include clinical practice guidelines, burn care, IV administration, pump operations and a host of other training topics to keep us on our toes and prepared for whatever comes through the door. All base medical personnel take part in the training, including our coalition partners, and there is generally a practical component to the training. For example, when learning about placing arterial lines, we pull out kits, put on gloves and practice with the equipment so that all medical personnel are familiar with the supplies and procedures to start a line.
Spc. Kurtz: The FST is where we learn the most in trauma training. It’s important to know what everyone else does and what they might need in order for things to run smoothly when patients come in. It looks like a mess in the aid station and FST’s area during trauma care, but it’s actually controlled chaos. Everyone knows what they are doing, and if someone needs something to do their job, we work together to make sure they get it. It’s really important that we work together and know each other’s job to provide the best care for our patients. Some of the training we do with the FST goes over my head at first because it is designed for higher levels of care, but the providers do a good job of re-explaining things until I understand and comprehend the skill.
Always on Call
Lt. j.g. Cook: We break for chow and after sitting to eat we’re notified of three incoming category alpha traumas (alphas being the most critical level). The three incoming patients are Afghan National Army soldiers who have hit an improvised explosive device on a patrol. We quickly put down our lunch and the medics and I scurry to make sure we’re ready to take patients. While they pass out gowns and gloves, I check the 9-line/MIST report (description of the casualties and injury severity) and verify their estimated time of arrival. These soldiers are coming in from the point-of-injury and will have only had basic interventions by the MEDEVAC crew. We establish our roles before they arrive and Kurtz is assigned as medic number one, who is responsible for obtaining IV access. I’ll be the lead provider at bed one in the aid station.
Spc. Kurtz: Usually when we go to pick up patients from dust-off, the helicopter comes in fast and the patients are already triaged. I pull the gator up, four people lift the patients in, the flight medic jumps in the back and we get the patient back to the aid station for treatment as fast as we can.
After the patients are searched, we work quickly to re-triage all of the patients to see who needs the most urgent care. The most critical patient goes to the Forward Surgical Team’s first bed, and the other goes to bed two. We treat the less critically wounded patient in the aid station down the hall from the FST. Despite my assignment on bed one, I end up bouncing between different patients as I’m needed. There are several medics from different nations stationed on base who come help us during traumas and we work together as a team, and across language barriers and varying levels of expertise, to provide the best care possible to our patients.
Lt. j.g. Cook: The two most critical patients are carried straight in to the FST, and within five minutes one of them is in the operating room. He needs surgery to open his abdomen, control bleeding, and assess damage from a shrapnel wound. In the aid station, Kurtz and I care for a young man who has sustained multiple superficial lacerations, a head injury and who also reports pain in his left cheek and left upper arm. One key person in our efforts to treat Afghan patients is our interpreter. He is critical when we work to get the patient’s medical history and he also stays right near the patient’s head throughout the process, to talk to him and answer his questions. As Kurtz starts an IV in his right arm, I perform a head-to-toe assessment of his condition and also run an ultrasound to check his abdomen for internal bleeding. Kurtz also monitors his vital signs. After completing my assessment, I order a tetanus shot and morphine for the soldier.
Spc. Kurtz: When more critical problems have been taken care of it’s time to start taking x-rays of our patient. We only take them if we suspect that the patient has broken bones, and want to rule out any other injuries. The x-rays themselves are not that hard to shoot, though the tough part is trying to place the camera and the patient’s body correctly so we get a picture of everything we need to see. Once we’re done with the x-ray, we prepare the patient for transfer to a more advanced medical facility. I grab the blizzard kit, which is used to prevent the patient’s body temperature from dropping, and lay everything out for transferring the patient to a new litter. Once I’m finished, we’ll be able to transfer our patient.
Lt. j.g. Cook: While reviewing the x-ray we discover a fractured jaw, separated shoulder and non-displaced fracture of the upper arm. Before we can do much more, we get word that a helicopter is on the way to pick up all three patients so they can be transferred to a facility better equipped to care for their injuries. Since we’re a Role I/II facility, we don’t have the capability to keep patients long-term. We stabilize them and send them to higher level of care, the Role III, which has inpatient beds and far more resources. We splint and wrap his arm, place it in a sling, clean and cover his lacerations, and after Kurtz packs the patient in a kit to keep him warm the patient is ready for transfer.
Spc. Kurtz: The helicopter touches down and our patient, along with the other two surgical patients, will be loaded and flown to the Role III. After a couple of hours of patient care, it’s time to clean up. It’s very important for us to clean our equipment and have it ready for the next patient because you never know when they’ll be coming through the door. There have been times where we get one patient out the door and there’s already more waiting to be dropped off at our aid station.
Lt. j.g. Cook: After successfully sending our patients off to the Role III, my team restocks and resets our aid station – another trauma could happen at any time and it must be ready. I have a few minutes to review and complete patient notes and send emails before attending an afternoon brief.
Spc. Kurtz: Time to go work out. As we move towards summer and the temperatures rise, I usually just hope that it isn’t so hot out that I can’t run more than a mile.
Lt. j.g. Cook: Time for the medical team’s workout of the day/PT time. Spc. Kurtz loves to PT and I think this is his favorite time of day. We have to fit it in when we can due to our unpredictable schedules. We sign out on a white board so we can be found quickly if needed. Warmer weather is around the corner, so we are enjoying the last few temperate days by running outside and cooling down on the roof.
Spc. Kurtz: Time to go eat and find something that looks appetizing. After eating, I read a book or write and try to keep myself busy. Time seems to go by much faster that way.
Lt. j.g. Cook: Back to the aid station for evening sick call hours. We have lots of folks working shifts and it’s easier for them to be seen in the evenings. Kurtz and I see a case of allergic rhinitis and treat a sprained hamstring after a 2-on-2 basketball game.
Spc. Kurtz: Time to go talk to my family if I can reach them. I also spend a good portion of my time doing school work, then relaxing and getting ready for bed. I need to make sure I rest when I can as you never know when we’ll get another patient in.
Lt. j.g. Cook: Time to wind down, pick up some laundry, make a quick call to Mom, then shower and settle in with a book before calling it a day. I have to be rested for the next patient which is always just around the corner.
Lt. j.g. Cook: Our medical team works hard taking care of patients every day and many nights, whether trauma or routine illness, and works equally hard at supporting one another. Being on-call 24/7 for the duration of a deployment can be exhausting mentally and physically, which is why having a solid team is critical to our success. It is a privilege to be part of this small group of Army medics and Navy corpsmen in the aid station. This deployment is my first opportunity to work alongside another service, on the same team, and it has been a great experience. We often compare Army and Navy terminology (Kurtz says “latrine” and I say “head”) and laugh good-naturedly at our different vocabularies. I will always remember this deployment and what an honor it’s been to serve with Spc. Kurtz.
Spc. Kurtz: It has been a privilege working with the Navy team. It is interesting to see how much the services differ from each other but how similar we really are. The mission comes first and then everything else after that. The vocabulary is one thing that I cannot get used to. When I first got here someone said it was time for a muster and I asked if they wanted some mustard. I later found out that a muster is when everyone gets together in the morning to find out what has to be done that day. Deployment has its ups-and-downs, and at this point I think everyone is ready to go and see their loved ones or go to their next assignment. This has been a good deployment and everything I’ve learned here I’ll take with me to my next command.